1. Suturing in the Pediatric ED Sujit Iyer, M.D.

2. Goals Review the fundamental history, preparation and techniques in suture repair in the ED Brief repair/pearls on how to make suturing more successful and less traumatic for pediatric patients Review discharge and follow up instructions

3. Checklist Type of Wound – Which do you close? Wound care – Foreign body? How deep is it? Choice of anesthetic – LET !?! Suture type

4. Should you close it? Close only clean wounds! – Dirty wounds: MOST animal bites, contaminated wounds you can not clean adequately Cosmetic wounds – the face! Wounds requiring hemostasis New wounds: less than 12 hours old (up to 24 hours on face) Wounds overlying joints (knee) – make sure not continuous with joint cavity – may need ortho consult to inject joint

5. Wound Care Irrigate it! Volume and pressure clear bacteria! – Use only saline or nontoxic surfactants Foreign bodies are rarely discovered unless you anticipate one! Consider using XR, CT, ultrasound when necessary – If grossly contaminated, irrigate and then XR Consider antibiotics for : – Contaminated wounds – Bite wounds – Crush wounds – Missile Wounds – Delayed wound closure

6. Irrigation technique

7. Wound Care Basics Always consider deeper damage and suture material needs: – Tendon, joint – Galea – Muscle/Fascia l

8. Anesthesia Infiltrative anesthesia (Lidocaine) – Can be painful, ? If other painless equally effective options (see LET) – Max dose: Without epi (4-5 mg/kg), with epi (5-7 mg/kg) – Consider nerve blocks to prevent toxicity for large wounds

9. Infiltrative Anesthesia – PLEASE CONSIDER TOPICAL ANESTHESIA (LET) WHENEVER POSSIBLE

10. TOPICAL ANESTHESIA Alternative to local infiltrative anesthesia LET gel – apply directly to wound with adhesive (i.e., Tegaderm) or with cotton ball and direct pressure Advantages: – NOT PAINFUL – May be only anesthetic needed for face or scalp – May decrease need for infiltrative anesthesia or at least decrease pain for trunk and extremity wounds – Blanching of surrounding tissue indicates onset of anesthesia – NO adverse side effects reported from systemic absorption

11. Anesthesia considerations in Pediatric laceration repair Anxiety equally (if not greater) component than pain. Tips to ease anxiety: – Child life consult – distraction techniques, explaining procedure, etc.. – Comfort positioning (see SLC module!) – Intranasal medicine (Versed, Fentanyl, or both) Use non painful anesthetics when possible (LET vs infiltrative lidocaine) Anxiety/pain of suture removal of non-absorbale sutures when absorbable suture equal cosmetic/functional option.

12. Sutures – The Basics to Consider Absorbable vs Non-absorbable – Absorbable: Fast absorbing gut, Chromic gut, Vicryl, PDS – Non-absorbable: Prolene, Ethilon, Silk Smaller the number (“O”) the bigger the thread Packaging will show actual needle size Curved needle for all ED needs

13. Which Suture, Where? ABSORBABLE Fast Absorbing Gut –Face Chromic Gut –Mucous membs, fingertip amputation Vicryl –Deep layers only PDS –Deep layers only NON-ABSORBABLE Prolene –Any skin surface Ethilon –Any skin surface Silk –Rarely: suturing tubes/lines in place

14. Which size; and for non-absorbable when do they come out? Use size…Take out in… Face6.0, 5.03-5 days Scalp5.0 or staples7-10 days Trunk/extremity4.0, 5.07-10 days High tension/ back 4.0, 3.010-14 days Mucous membrane 5.0 chromic gut no need

15. Let’s get started…

16. How to suture…

17. Discharge Instructions Watch for signs of infection Topical or oral antibiotics when indicated Suture removal timing if using non-absorbable Tetanus? (look up if indicated) How Do I minimize scar formation? – Keep area clean, proper suture removal if indicated – Sublock and Vitamin E (Scars form over the next 6 months to 1 year)